lower gi bleeding 4/6/11. lgib distal to ligament of treitz annual incidence rate of 20.5/100,000 ...

23
LOWER GI BLEEDING 4/6/11

Upload: connor-haddon

Post on 01-Apr-2015

216 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

LOWER GI BLEEDING

4/6/11

Page 2: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

LGIB

Distal to ligament of Treitz Annual incidence rate of 20.5/100,000 Male predominance Incidence of significant bleeding

increases with age May suggest changes associated with

the small intestine and colon Reflects the prevalence of diverticulosis

and angiodysplasia in the elderly

Page 3: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

LGIB

May present as melena or hematochezia Melena typically suggests bleeding from a

more proximal source (colon or small intestine)

Hematochezia suggests left colonic, rectal, or anal sources

Upper gastrointestinal hemorrhage may present with rectal bleeding given blood’s cathartic effect and rapid intestinal transit (10-15% of cases)

Page 4: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

LGIB

Most often the intestinal bleeding resolves spontaneously

Once it resolves, investigations should begin to identify the potential sources

On occasion, the intestinal hemorrhage does not resolve Creates hemodynamic compromise

Ongoing hemorrhage demands aggressive medical and surgical management

Oftentimes patients are plagued with significant comorbidities that complicate their individual resuscitation

Comorbidities must be considered in the diagnostic and therapeutic phases of the care plan

Current increased patient exposure to antiplatelet therapy associated with treatment of cardiovascular conditions may increase the comorbid challenges in patients with lower gastrointestinal massive hemorrhage

Page 5: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Etiology

Diverticula Angiodysplasia Ischemic colitis Inflammatory bowel disease Intestinal tumors or malignancies NSAID-related nonspecific colitis Meckel’s diverticulum Anorectal diseases

Page 6: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Diverticular disease

Outpouchings of the mucosa and submucosa through defects in the muscular layer of the bowel at sites of penetration of the vasa recta

Thinning of the media in the vasa recta predisposes to intraluminal rupture: focal injury may occur from trauma related to a fecalith

incidence spans a range of 15% to 48% relatively rare event affecting only 4%–17% of

patients with diverticulosis

Page 7: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Diverticular disease

Operative management is indicated when bleeding continues unabated and is not amenable to angiographic or endoscopic therapy

Should be considered in patients with recurrent bleeding localized to the same colonic segment

In a stable healthy patient, the operation consists of a segmental bowel resection (usually a right colectomy or sigmoid colectomy) followed by a primary anastomosis

Page 8: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Angiodysplasia

Thin-walled arteriovenous communications located within the submucosa and mucosa of the intestine

May be congenital or acquired, isolated or multiple

In the acquired form, distortions of the postcapillary venules may arise as a degenerative lesion associated with increases in intraluminal pressure Results in thickening and ectasia

The vessels eventually entangle as tufts within the submucosa and erode into the mucosa proper

Page 9: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Angiodysplasia

Colonoscopic criteria Mucosal surface

contains a cherry red lesion that is typically flat

Greater than 2 mm in size

Have a “fern-like” appearance

A central feeding vessel is not always visible

Page 10: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Occult Hemorrhage

Occurs infrequently no more than 5% of all patients admitted with

LGI massive hemorrhage Frequent recurrences create chronic anemic

states in patients and require occasional admissions for transfusions

May harbor angiodysplasias in the small intestine or right colon

May benefit from small bowel contrast radiography or capsule endoscopy

Elective angiography with cecal magnification may reveal small angiodysplasias

Page 11: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Occult Hemorrhage

If the hemorrhage recurs and investigations fail to reveal the source, a variety of provocative diagnostic angiographic studies have been described Most studies prefer to incite bleeding using either

heparin or thrombolytics Once the site of bleeding is identified, it may be

difficult to control without surgery Prepare and hold an operating room

Once the location is identified, a superselective catheter is left in the distal artery

During surgery, the surgeon can palpate the catheter within the vessel and direct the surgical resection

Page 12: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Initial Assessment

Establish IV access (large bore) and start IV fluids restore volume and replete red blood cell

deficiencies Labs

CBC, electrolytes, coags, type and cross All coagulopathies require reversal! NG tube placed will screen for the presence of

upper gastric sources for bleeding Kovacs and Jensen noted 17.9% of LGI hemorrhage

presentations involved an upper gastrointestinal source

NG tube is effective in detecting prepyloric hemorrhage

Page 13: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Evaluation

Digital anorectal examination and anoscopy

Rigid proctosigmoidoscopy will allow the examiner to evacuate the rectum of blood and clots Excludes internal hemorrhoids, anorectal

solitary ulcers, neoplasms, and colitis Colonoscopy and angiography offer

therapeutic intervention Nuclear scanning is purely diagnostic

Page 14: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Evaluation

subdivide patients into 3 general clinical categories minor and self-limited major and self-limited major and ongoing

Major ongoing hemorrhage requires prompt intervention with angiography or surgery

Minor, self-limited may undergo colonic lavage and colonoscopy within 24 hours

Major, self-limited need diagnostic tests to determine if they require prompt therapy or observation

Page 15: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Radionuclide imaging

Detects the slowest bleeding rates 0.1–0.5 mL/min

More sensitive than angiography Unfortunately cannot reliably localize the site

of hemorrhage The specificity of small bowel versus large

intestine bleeding does not reliably compare with angiography

Two general techniques technetium sulfur colloid scans 99mTc pertechnetate-tagged RBCs

Page 16: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Radionucleotide imaging

Immediate positive blush (within the first 2 minutes of scanning) highly predictive of a positive angiogram

(60%) predictive for surgery in 24%

If study did not demonstrate a blush highly predictive of a negative angiogram

(93%) the need for surgery decreased to 7%

Page 17: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Colonoscopy

If the patient appears stable with self-limited hemorrhage, colonoscopy is the preferred diagnostic study

Major benefit depends on ability to provide a definitive localization of ongoing active bleeding and the potential for therapy

Many landmarks for colonoscopy may be obscured during hemorrhage

Once the endoscopist highlights a bleeding source, the region requires a tattoo to mark the site

If the hemorrhage continues and fails medical management, the tattoo assists in localizing the hemorrhage

Therapeutic armamentarium i thermal agents such as heater probes, bipolar coagulation,

and laser therapy Injection therapy uses topical and intramucosal epinephrine Mechanical therapy includes endoscopically applied clips

Page 18: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Angiography

Diagnostic and therapeutic Acute, major hemorrhage with ongoing

bleeding requires emergency angiography Patients with an early blush during nuclear

scintigraphy may benefit from therapeutic angiography

May define a potential source for hemorrhage in occult and recurrent gastrointestinal hemorrhage

Requires a hemorrhage rate of at least 1 mL/min Yields range from 40% to 78%

Page 19: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Angiography

Highly accurate localization provides for focused therapy Intraarterial vasopressin infusion

0.2 U/min up to 0.4 U/min Systemic effects and cardiac impact may limit maximizing the dosage Controls bleeding in 91% of patients Bleeding may recur in up to 50% of patients

Arterial embolization Superselective mesenteric angiography with microcatheters in the

vasa recta Vessels as small as 1 mm Risk of intestinal infarctions of larger selective vessels may exceed 20% Provides immediate arrest of the bleeding Combination of agents to control bleeding

Gelfoam pledgets, coils, and polyvinyl alcohol particles Arteriography also has complications

arterial thrombosis, distant arterial emboli, and renal toxicity from dye

Page 20: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Operative therapy

Few patients currently require surgical treatment Hemodynamically unresponsive to initial resuscitation Site of hemorrhage localized, but available

therapeutic interventions fail to control the bleeding Patient mortality increases with their transfusion

requirements Once reaches 6–7 units and the hemorrhage remains

ongoing, surgical intervention becomes eminent First objective in surgery focuses on the location of

the intraluminal blood with the goal of segmentally isolating the possible sources of bleeding

if no source appears obvious, may consider intestinal enteroscopy

Page 21: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Operative therapy

If the source of bleeding cannot be found, and it appears to arise from the colon, the surgeon should perform a subtotal or total colectomy Stable patients will tolerate a primary ileosigmoid

or ileorectal anastomosis Unstable patients require an end ileostomy with

closure of the rectal stump or a mucous fistula Once stable, the patient may return for

ileostomy closure. The rectum and sigmoid colon require

reexamination endoscopically to assure no bleeding persists.

Page 22: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding

Algorithm

Page 23: LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding